Reassessment of the predictive value of the Forrest classification for peptic ulcer rebleeding and mortality: can classification be simplified?

BACKGROUND AND STUDY AIMS: This study aimed to reassess whether the Forrest classification is still useful for the prediction of rebleeding and mortality in peptic ulcer bleedings and, based on this, whether the classification could be simplified. PATIENTS AND METHODS: Prospective registry data on peptic ulcer bleedings were collected and categorized according to the Forrest classification. The primary outcomes were 30-day rebleeding and all-cause mortality rates. Receiver operating characteristic curves were used to test whether simplification of the Forrest classification into high risk (Forrest Ia), increased risk (Forrest Ib-IIc), and low risk (Forrest III) classes could be an alternative to the original classification. RESULTS: In total, 397 patients were included, with 18 bleedings (4.5%) being classified as Forrest Ia, 73 (18.4%) as Forrest Ib, 86 (21.7%) as Forrest IIa, 32 (8.1%) as Forrest IIb, 59 (14.9%) as Forrest IIc, and 129 (32.5%) as Forrest III. Rebleeding occurred in 74 patients (18.6%). Rebleeding rates were highest in Forrest Ia peptic ulcers (59%). The odds ratios for rebleeding among Forrest Ib-IIc ulcers were similar. In subgroup analysis, predicting rebleeding using the Forrest classification was more reliable for gastric ulcers than for duodenal ulcers. The simplified Forrest classification had similar test characteristics to the original Forrest classification. CONCLUSION: The Forrest classification still has predictive value for rebleeding of peptic ulcers, especially for gastric ulcers; however, it does not predict mortality. Based on these results, a simplified Forrest classification is proposed. However, further studies are needed to validate these findings.

Polimorfismos genéticos de interleucinas IL-1B-511, IL-1RN, IL-10, factor de necrosis tumoral alfa-308 e infección por Helicobacter pylori CagA positivo en cáncer gástrico y úlcera duodenal en diferentes poblaciones en Colombia / Genetic polymorphisms of IL-1B-511, IL-1RN, IL-10 interleukins, tumor necrosis alfa-308 and Positive Helicobacter pylori CagA infection in gastric cancer and duodenal ulcer in different populations in Colombia

Objetivo: Determinar la asociación entre los polimorfismos IL-1B-511, IL-1RN, TNF-α-308, IL-10-819 e IL-101082 y la infección por Helicobacter pylori CagA positivo en un grupo de pacientes con cáncer gástrico y úlcera duodenal en diferentes poblaciones en Colombia. Métodos: Estudio de casos y controles con 341 pacientes: con gastritis no atrófica, 194; con cáncer gástrico, 58; úlcera duodenal con lesiones preneoplásicas, 54; y con úlcera duodenal, 35. La genotipificación de los polimorfismos se hizo por discriminación alélica usando PCR en tiempo real, y la del IL-1RN, por PCR convencional y electroforesis en agarosa. La infección por Helicobacter pylori CagA se determinó mediante ELISA. Se utilizó la regresión logística en el análisis estadístico. Resultados: Ser portador del genotipo IL-1B-511TT (OR=4,69; IC 95% 1,22-18,09) y tener una infección por Helicobacter pylori CagA positivo (OR=4,43; IC 95% 1,72-11,4) se asociaron a cáncer gástrico. Tener una infección por Helicobacter pylori CagA positivo (OR=4,39; IC95% 1,82-10,59) se asoció a la presencia de úlcera duodenal con lesiones preneoplásicas, y ser portador del genotipo IL-1B-511CT se asoció a úlcera duodenal (OR=0,30; IC 95% 0,10-0,91). Conclusión: Los resultados sugieren que la respuesta pro-inflamatoria y la genética virulenta de la bacteria son factores relacionados con los diferentes desenlaces ocasionados por la infección por Helicobacter pylori en la población estudiada; así, el polimorfismo IL-1B-511 es un factor relacionado con cáncer gástrico y úlcera duodenal, y la infección por Helicobacter pylori CagA positivo es un factor asociado a cáncer gástrico y úlcera duodenal con lesiones preneoplásicas.

Objective: To determine the association between the IL-1B-511, IL-1RN, TNF-α-308, IL-10-819 and IL-101082 polymorphisms and positive Heliocobacter pylori CagA infection in a group of patients with gastric cancer and duodenal ulcer in different populations in Colombia. Methods: A case-control study was performed on 341 patients: those with non-atrophic gastritis, 194; with gastric cancer, 58; duodenal ulcer with preneoplastic lesion, 54; and with duodenal ulcer, 35. The genotyping of polymorphisms was done with allelic discrimination using PCR in real time, and that for IL-1RN with conventional PCR and agarose electrophoresis. Helicobacter pylori CagA infection was ascertained with ELISA. Logistic regression was used in statistical analysis. Results: Being a carrier of genotype IL-1B-511TT (OR=4.69; CI 95% 1.22-18.09) and being positive for Helicobacter pylori CagA infection (OR=4.43; CI 95% 1.72-11.4) are associated with gastric cancer. Positive Helicobacter pylori CagA infection (OR=4.39; CI 95% 1.82-10.59) is associated with the presence of duodenal ulcer with preneoplastic lesions, being a carrier of genotype IL-1B-511CT is associated with duodenal ulcer (OR=0.30; CI 95% 0.10-0.91). Conclusion: The results suggest that pro-inflammatory response and virulent bacterial genetics are factors related to the different outcomes brought about by Helicobacter pylori infection in the population studied; that is, the IL-1B-511 polymorphism is a factor related to gastric cancer and duodenal ulcer, and positive Helicobacter pylori CagA infection is a factor associated with gastric cancer and duodenal ulcer with preneoplastic lesions.

Giant duodenal ulcers.

Giant duodenal ulcers (GDUs) are a subset of duodenal ulcers that have historically resulted in greater morbidity than usual duodenal ulcers. Until recently, few cases had been successfully treated with medical therapy. However, the widespread use of endoscopy, the introduction of H-2 receptor blockers and proton pump inhibitors, and the improvement in surgical techniques all have revolutionized the diagnosis, treatment and outcome of this condition. Nevertheless, GDUs are still associated with high rates of morbidity, mortality and complications. Thus, surgical evaluation of a patient with a GDU should remain an integral part of patient care. These giant variants, while usually benign, can frequently harbor malignancy. A careful review of the literature highlights the important differences when comparing GDUs to classical peptic ulcers and why they must be thought of differently than their more common counterpart.

[Characteristics of the different variants of the complex treatment of stomach ulcer]. / Kharakteristika razlichnykh variantov kompleksnogo lecheniia iazvennoi bolezni.

The eradication therapy increases the speed of cicatrisation of ulcers in the gastroduodenal zones in infected patients. The best method to increase the efficiency of ulcer cicatrisation is reflex therapy for patients at the age of 22-50 years and laser therapy for older patients.

[Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery]. / Le traitement laparoscopique de l'ulcère duodénal perforé. Résultats d'une étude rétrospective multicentrique. Société française de chirurgie laparoscopique (SFCL).

STUDY AIM: The aim of this multicentric retrospective study was to report procedures, mortality and morbidity rate in a series of patients operated on for perforated duodenal ulcer with a laparoscopic approach. PATIENTS AND METHODS: Four-hundred and nineteen patients from 18 centers were included. The duration of the study was ten years (1990 to 1999). There were 299 men and 120 women aged from 19 to 98 years (mean: 48 years). The ASA scores were as follows: I (48.7%), II (31.3%), III (17.5%), IV (2.5%). The mean duration between the onset of perforation and the time of operation was 13.4 hours (range: 1-70). The surgical procedures were suture (76.7%), epiploplasty (9.9%), only irrigation of the abdominal cavity (2.7%). RESULTS: Conversion into laparotomy was performed in 10.6% of the patients. Mean operative time was 85 minutes. The morbidity and mortality rates were 13.4 and 1.4% respectively. Seventeen patients were reoperated because of fistula (n = 5), intra-abdominal abscess (n = 5), small bowel obstruction (n = 4), bleeding ulcer (n = 1), iatrogenic perforation of the gallbladder (n = 1) and small bowel (n = 1). Mean hospital stay was 8.5 days. All patients were discharged with a medical treatment of the peptic ulcer disease and in most of the cases, with antibiotics for Helicobacter pylori eradication. Six patients out of 96 with a medical history of chronic peptic ulcer underwent a vagotomy. CONCLUSION: Laparoscopic repair of perforated duodenal ulcer is a safe option providing low rates of morbidity, reoperation and mortality, and can be considered the treatment of choice.

Ultrastructural study of the gastric mucosa and Helicobacter pylori in duodenal ulcer patients.

OBJECTIVE: To investigate the relationship between Helicobacter pylori and gastric mucosa in control and duodenal ulcer patients at the electron microscopic level. METHODS: Three antral biopsies were taken from each of 20 normal control volunteers and 30 duodenal ulcer patients presented to the gastroenterology unit at Jordan University Hospital for upper endoscopic examination. Each specimen was fixed and processed for electron microscopic study. RESULTS: Two types of Helicobacter pylori were observed and identified by their morphology at electron microscopy. The first one was characterized by double external smooth membranes and homogeneous cytoplasmic contents, and the second type with a characteristic ring-shaped intracytoplasmic vacuole. Electron microscopic examination of normal controls showed normal gastric mucosa and a small number of Helicobacter pylori in 12 out of 20 controls. However, in duodenal ulcer patients, 5 different patterns of interaction between the Helicobacter pylori and gastric mucosa were observed in relation to the severity of the disease. In duodenal ulcer patients, various types of epithelial damage was seen accompanied with a decrease or absence of mucous secretion and with more colonization of bacteria. CONCLUSION: The morphology and pathogenesis of Helicobacter pylori was described in duodenal ulcer patients, and 5 different patterns of contact between Helicobacter pylori and surface epithelium were recognized causing variable degrees of microvillous atrophy and reduced mucous secretion. The vacuolated type of Helicobacter pylori was more adherent to the damaged epithelium and there was a direct relationship between the epithelial damage and bacterial load. In the normal controls, no epithelial damage and scanty bacteria were observed. The various types of epithelial changes of gastric mucosa has initiated more research at electron microscopic level on the immune mechanism of the gastric mucosa to determine the underlying cause of the varying severity of the disease.

[The individualized choice of the method of operation in the planned surgery of gastric and duodenal peptic ulcers]. / Individualizirovannyi vybor sposoba operatsii v planovoi khirurgii iazvennoi bolezni zheludka i dvenadtsatiperstnoi kishki.

A working classification of gastroduodenal ulcers was developed by the authors on the basis of surgical treatment of 1838 patients with ulcer disease of the stomach and duodenum. When used in combination with the complex examination of the patients it allows to individually choose the operative method. The indications and contraindications for different kinds of surgery are given. Specific features of the postoperative management are described.

[Long-term results of abdominal surgery interventions. Different evaluation from the viewpoint of the patient, the surgeon and the public health office]. / Langzeitergebnisse nach abdominalchirurgischen Eingriffen. Unterschiedliche Beurteilung aus der Sicht der Patienten, des Operateurs und des Versorgungsamts.

The patient, the surgeon and the public health officer (Versorgungsamt) assess the long-term results of abdominal operations differently. We tried to objectivize these different assessments. The clinical data were collected retrospectively. Data on postoperative subjective state and degree of handicap were obtained in a written patient survey (March 1995). Two groups with benign diseases and one group with malignant disease were examined: 59 patients who had undergone sigmoidectomy for diverticulitis (30 female and 29 male patients, median age: 61.5 years), 347 patients subjected to proximal gastric vagotomy for duodenal ulcers (72 female and 275 male patients, median age: 46 years) and 158 patients who had undergone gastrectomy for gastric carcinoma (56 patients female, 102 patients male, median age: 61 years). The public health officer, classed 35.6% of the patients who had undergone sigmoidectomy and 34.6% of the patients who underwent vagotomy as officially handicapped with a stated grade of disablement, 77.2% of the patients with gastrectomy were officially classed as handicapped. When other diseases were taken into account in addition, 27.1% of the patients who had undergone sigmoidectomy, 27.4% of those who had undergone vagotomy and 75.9% of the patients with gastrectomy had received passes officially identifying them as severely handicapped persons. In the vast majority of cases, the combination of several different ailments had resulted in recognition of a graded handicap and severely disabled person's pass, skeletal, cardiac and circulatory ailments being the most frequent. In spite of this, the evaluation of post-operative course by our patients, the surgeon and the public health officer (as reflected in the official state classification) in terms of the degree of handicap clearly differed.

Endoscopic re-evaluation of Visick grading.

Correlation of Visick grading was done with serial endoscopies in 19 patients operated for duodenal ulceration. Deeper mucosal lesions like ulceration showed good association with Visick grading (100%), while superficial mucosal lesions were mostly asymptomatic and therefore, caused disparity in grading. Moreover, as symptoms and endoscopic findings changed with passage of time, it was concluded that in the light of endoscopic findings the grading need re-evaluation.

Enfermedad péptica del duodeno: radiodiagnóstico, clasificación e incidencia en Tucumán / Duodenal peptic disease: classification in double contrast barium studies

Experiencia de 1.336 exámenes S.E.G.D. desde marzo de 1993 hasta marzo de 1994, de los que 792 (59,3 por ciento) son de sexo femenino y 544 (40,7 por ciento) masculino. En 198 casos (14,8 por ciento) presentó patología duodenal, de los que 158 (79,8 por ciento) corresponden a Enfermedad Péptica Duodenal (E.P.D.) y 40 (20,2 por ciento) a otras patologías. Se describe la Técnica de Doble Contraste y se presenta una clasificación desde el punto de vista de la imagen pesquisada y sus similitudes y diferencias con la clasificación de O.M.E.D. (Organización Mundial de Endoscopía Digestiva) (AU)

Enfermedad péptica del duodeno: radiodiagnóstico, clasificación e incidencia en Tucumán / Duodenal peptic disease: classification in double contrast barium studies

Experiencia de 1.336 exámenes S.E.G.D. desde marzo de 1993 hasta marzo de 1994, de los que 792 (59,3 por ciento) son de sexo femenino y 544 (40,7 por ciento) masculino. En 198 casos (14,8 por ciento) presentó patología duodenal, de los que 158 (79,8 por ciento) corresponden a Enfermedad Péptica Duodenal (E.P.D.) y 40 (20,2 por ciento) a otras patologías. Se describe la Técnica de Doble Contraste y se presenta una clasificación desde el punto de vista de la imagen pesquisada y sus similitudes y diferencias con la clasificación de O.M.E.D. (Organización Mundial de Endoscopía Digestiva)

The ulcer disease: an updated classification system.

The study included 736 probands with ulcer disease and 110 healthy subjects as well as all their relatives up to a third-degree of relation (n = 21889). All subjects underwent a thorough genealogical analysis, blood group, PTC and dermatoglyphic studies were performed on the whole contingent. Using extensive genealogical, genetico-mathematical and multifactorial analysis we studied the manifestations of anticipation, the influence of hereditary predisposition on gastric secretion and acidity under conditions of maximum pentagastrin stimulation as well as the disease inheritance pattern. The results of our comprehensive studies suggest that type I gastric ulcer according to H. Johnson, unlike type II and type III, is not genetically determined. On the other hand, type II and type III gastric ulcer do not differ substantially from duodenal ulcer and should therefore be categorised as belonging to this form of the disease. On this basis we propose a new classification system which accepts the existence of two ulcer diseases: gastric ulcer disease, and ulcer disease of the pyloroduodenal region.

Influence of the type of family predisposition on the age of ulcer disease onset.

736 probands with endoscopically and/or roentgenologically proven ulcer disease of the stomach and duodenum were studied. Of these 429 were with hereditary predisposition to the disease (including in the study all their third-degree relatives). Our findings suggest that the age of disease onset is markedly dependent on the type of familial predisposition. It occurs the earliest and relatively the most frequently in probands with two affected parents (familial predisposition type III). The peak frequency of the disease for non-predisposed subjects is between 30 and 39 years of age while in subjects with familial predisposition of the first type (two healthy but genetically predisposed parents) the II-A type (a sick father) and the II-B type (a sick mother) it occurs a decade earlier. Type III familial predisposition causes the disease to affect the probands even earlier by another decade so half of all the probands of this type of familial predisposition are affected by the disease by the age of 19. The different types of familial predisposition to gastric ulcer (types II and III) and duodenal ulcer reflect the hereditary ulcerogenic load received by the offspring. All other conditions being equal, the greater it is the earlier the disease occurs.

[Clinical observation on 80 cases with duodenal bulbar ulcer treated with kuiyangqing pill].

UNLABELLED: 80 patients with duodenal bulbar ulcer were divided into two groups: one was the group of ulcer with Excess-Heat Syndrome (EHS); the other was that with Deficiency-Cold Syndrome (DCS). Both groups of patients were treated with Kuiyangqing Pill (KYQP) for observation, 32 cases treated with bismuth aluminate tablets as control. RESULTS: The therapeutical effect of EHS was better than that of the control. The recovery rate was 91.5%. The effective rate was 97.9% (P < 0.05). While the curative effect of DCS group was not so good as that of the control.